Few smiles as rural areas struggle with dental care
By Larry Dreiling
It’s been well reported that rural America has a shortage of doctors. Perhaps, not surprisingly, but a bit underreported is a shortage of dentists as well. It’s a shortage every bit as pronounced, if not more so, than the shortage of doctors, according to a report by the Kansas Health Foundation.
“We’re facing a dental crisis in the state,” Steve Coen, KHF president, said. “Of the 105 counties in Kansas, 93 have too few dentists, and 13 have none. Too many adults and children are living in pain.”
A 2011 report done by researchers at the University of Kansas Medical Center found that at least 57,000 Kansans live in “dental deserts,” areas where the closest dental office is at least a half-hour’s drive from where they live.
Additionally, in many of those 93 counties, patients must wait months for an appointment.
Daniel Minnis, D.D.S., from Pittsburg, Kan., sees the problem firsthand.
“It is not uncommon for a child to wait two months for a restorative dental appointment,” Minnis said, in a KHF report on the dentist shortage.
This shortage of dental care is only going to get worse. It’s estimated that by 2045, there will be fewer than 30 practicing dentists for every 100,000 Kansans.
“We are seeing that people are turning to emergency rooms because they can’t see a dentist,” Shannon Cotsoradis, president of the Kansas Action for Children, said in the same KHF report. “In 2010, there were more than 17,500 ER visits because of dental care, with the No. 1 reason being cavities.”
A possible solution
The solution many in the health care field see for the shortage of dentists is one similar to the shortage of doctors. The physician’s assistant has long been seen as one part of the solution to the equation of the shortage of medical practitioners in rural America.
Similarly, the Registered Dental Practitioner program is an emerging effort nationwide designed as a mid-level provider, similar to a physician’s assistant, that will increase access to dental care.
Under this model, registered dental hygienists can complete additional education and training to become RDPs. With the supervision of a dentist, the RDP is able to provide preventive care, cleanings, extractions and fillings.
In Kansas, a proposed law would require RDPs to spend their first 500 hours of practice under the direct supervision of a licensed dentist before having the freedom to practice at a more remote site, usually with a dentist offering direction via telemedicine.
A similar model is already in place in more than 50 nations, as well as Alaska and Minnesota.
“Adding one RDP to a practice can allow at least 2,000 additional appointments a year,” Cotsoradis said. “This program is critical to increasing the reach in safety-net clinics where they often have waiting lists.”
“With the RDP as part of the dental team,” Minnis said, “many of these patients will be able to receive their needed dental care at the same appointment as their initial examination or within a few days, rather than months.”
RDPs in Alaska and Minnesota came about despite fierce opposition by some mainstream dental groups. Two dentists who work with RDPs are attesting to their abilities in YouTube videos, released by The Pew Charitable Trusts.
In one, John T. Powers, D.D.S., a private-practice dentist in Montevideo, Minn., says working with an RDP has helped him expand access to care in his rural town with a population of about 5,400 people. The therapist, trained to perform procedures including pulpotomies, extractions and to place stainless steel crowns has freed him to do more time-consuming and complex procedures, Powers says.
In a second, Shiraz Asif, D.D.S., clinic dental officer at a community health clinic in Minneapolis, also describes the perks of working with therapists.
“They’ve turned out to be a great help,” Asif says.
Pew, as well as the W.K. Kellogg Foundation and other philanthropies and grassroots organizations, continues to work to get therapists into place in states where care is lacking.
In 2010, Pew issued a report, “It Takes A Team,“ exploring the potential benefits of adding RDPs to dental practices.
Among the report’s findings:
In solo private dental practices, where most dentists work, adding new types of providers and dental hygienists produced gains in productivity and increased earnings by a range of 17 percent to 54 percent.
Dentists who operate a practice by themselves can increase their pre-tax profits by 6 percent or 7 percent by accepting more Medicaid-enrolled children and hiring either an RDP or a hygienist-RDP.
But mainstream dental groups, including the American Dental Association, have fought back hard, arguing the model is not the answer to shortage of care in poor, isolated and rural areas. The ADA says that raising Medicaid reimbursement rates would do far more to solve the problem.
“The major problem with access disparities is the lack of reasonable Medicaid reimbursement rates,” the ADA said. “This fact, although acknowledged, is not fully appreciated in the Pew report. Instead, the Pew report suggests that access disparities are a dental workforce issue. This cannot be further from the truth.”
The ADA’s own analysis concluded the RDP model would drive down the cost and price of dental care and the income of dentists while doing little to increase utilization of dental services.
RDF training ‘simply not adequate’
Kevin Robertson, the executive director of the Kansas Dental Association dental association’s chief executive, also has urged the Kansas Legislature to raise Medicaid reimbursements as a way to improve access to oral health care.
KDA also announced a scholarship program for dental school graduates who agree to locate in an underserved area.
But one thing most dentists simply will not support, Robertson has said in earlier phases of the dispute, is allowing non-dentists to drill and fill teeth.
“A maximum 18-month training is simply not adequate for a dental hygienist to learn restorative dental surgical procedures, science, anatomy and emergency treatments,” Robertson said in an April 2012 interview with KHI News Service.
He has said the proposals to license mid-level providers in Kansas would lower the standard of care to all patients.
A geographic argument
As is often the case in states with a large division of urban and rural interests, the issue of the establishment of RDPs is in a pitched battle not of party but of geography. Rural interests as well as some inner city advocates are pushing for RDPs to serve the underserved while dentists in the suburbs are pushing for the status quo, thinking that RDPs will lower their incomes.
In a 2007 poll, 81 percent of dentists oppose granting dental hygienists more independence, according to The Wealthy Dentist blog. If you break the results down by geography; however, there’s a big difference. Fifty-eight percent of rural dentists supported the idea, compared to just 12 percent of urban dentists.
For two years, the Kansas Legislature has debated the issue of RDPs, with no resolution to the arguments between the Kansas Dental Association and the Kansas Dental Project, the two primary lobby groups in conflict over the issue.
The Kansas Dental Project is a group led by Kansas Action for Children, Kansas Association for the Medically Underserved, and the Kansas Health Consumer Coalition, United Health Ministry Fund, HealthCare Foundation of Greater Kansas City, and the W. K. Kellogg Foundation.
Additional funding comes from the Kansas Health Foundation, which is the major funder of the Kansas Health Institute, the parent organization of KHI News Service, whose reportage over the last two years is acknowledged in the development of this feature. KHI News Service’s purpose is to be an objective source for health news for policy makers, media and the public.
The gridlock entered a new phase last summer, KDA and KDP agreed to share the cost of a professional mediator and entered into formal mediation with the goal of finding a compromise they can take to the Legislature for consideration.
But deliberations aimed at resolving the dispute ended without agreement,
“There was mediation, and it was good that we had the discussion,” said Christie Appelhanz, vice president in charge of public affairs at Kansas Action for Children and KDP spokesperson. “But it did not end in compromise.”
Appelhanz spoke Nov. 4 at a meeting of the KDP coalition.
She said the group would be “moving forward” in the upcoming 2014 session with the legislative package that it supported during this year’s legislative session.
“What happened in mediation doesn’t change our strategy,” she said.
Meanwhile, KDA’s Robertson did not respond to calls from KHI News Service seeking comment.
Appelhanz said the two sides met for the last time on Oct. 9.
Over the summer and fall, the coalition has grown to include more than 50 members, including organizations as diverse as Americans for Prosperity-Kansas Chapter, the Prairie Band Potawatomi Nation, and associations representing the state’s nursing homes and community mental health centers, Applehanz said.
Appelhanz said one of the state’s three KanCare managed care companies, Sunflower State Health Plan, recently became a member.
“We’re waiting to hear back from the other two” KanCare companies, she said.
Also, coalition members heard from Jeff Bartleson, senior manager with Children’s Dental Services, a program that provides dental care for low-income children in Minnesota.
Bartleson said access to mid-level dental providers has allowed Children’s Dental Services there to make major inroads in reaching children who previously had little or no access to dental care.
The often-expressed fear by dentists that patient care would suffer, he said, has not materialized. Minnesota has licensed mid-level providers since 2010.
Education: A limiting factor
One limiting factor to creating an RDF licensing procedure is that Kansas has no dental school. One university that has announced it was willing to begin an RDF program is Fort Hays State University, in Hays, Kan.
It’s not just the poor, underserved, or uninsured who have trouble accessing dental care in western Kansas. Even a college president can have trouble.
“I can’t get dental services where they accept our Delta Dental Blue Cross/Blue Shield plan,” said FHSU President Edward Hammond. “As a state employee, I get—and pay for—dental insurance, but the dentists in western Kansas don’t accept it.”
Hammond says he’s had to switch dentists three times to find someone who would accept his dental insurance. There are 13 primary care dentists in the Hays area, but Hammond says only a few accept Delta Dental Blue Cross/Blue Shield.
“The shortage is impacting not just the indigent, not just the children. It’s impacting all of Kansans in western part of the state,” he said.
FHSU has developed a similar type of education program for medical diagnostic imaging specialists. This program would be the model for the RDP proposal, Hammond said.
Ask the dentists
Hammond referred to Melinda Miner, D.D.S., of Hays, as someone who backs the RDP program.
Miner said to Kansas Public Radio that people will drive long distances for major dental problems, but they’re less likely to do so for the kind of routine care that can prevent more serious issues.
“You know, having to take your child out of school, take half a day off work, drive 30 minutes or more to go to the dentist for a routine checkup or preventive care is a lot less likely to happen than if you have a preventive person in your town,” Miner said.
That means they’d start out in the Hays clinic, just down the hall from Miner and her husband, who is also a dentist. Once they’re placed in the outreach clinics, they’d be under “general supervision.” Miner said telemedicine would make it possible to supervise a practitioner work without being at the same location. Minnis sees the RDP proposal in philosophical terms.
”If the Legislature sees that the Kansas Dental Association is not looking out for the best interests of the general public...that is, if they stonewall this, then the Legislature is liable to accept a dental mid-level provider proposal,” said Minnis, who helped write the latest proposal put before the Legislature last session.
“If you refuse to put providers out in areas where we have dental shortage areas, who suffers? It’s the children, the vulnerable populations, the frail elderly and handicapped,” he said.
Minnis said he was glad to see the parties sit down but was skeptical that a meaningful compromise would be struck.
“I think it’s just one of those things where, until the Legislature does something, we’re not going to get any closer to it,” he said.
Though it would take a few years for the proper infrastructure to be developed for the program, Minnis is ready for it to begin.
“I would hire a Registered Dental Practitioner in my private practice tomorrow,” he said, “and allow them to perform procedures within their scope on myself, my family members and my patients.”
Larry Dreiling can be reached by phone at 785-628-1117 or by email at firstname.lastname@example.org.